Endovascular therapy in the distal neurovascular territory: results of a large prospective registry

Abstract

BackgroundThere is a paucity of data regarding mechanical thrombectomy (MT) in distal arterial occlusions (DAO). We aim to evaluate the safety and efficacy of MT in patients with DAO and compare their outcomes with proximal arterial occlusion (PAO) strokes.MethodsThe Trevo Registry was a prospective open-label MT registry including 2008 patients from 76 sites across 12 countries. Patients were categorized into: PAO: intracranial ICA, and MCA–M1; and DAO: MCA–M2, MCA–M3, ACA, and PCA. Baseline and outcome variables were compared across the PAO vs DAO patients with pre-morbid mRS 0–2.ResultsAmong 407 DAOs including 350 (86.0%) M2, 25 (6.1%) M3, 10 (2.5%) ACA, and 22 (5.4%) PCA occlusions, there were 376 DAO with pre-morbid mRS 0–2 which were compared with 1268 PAO patients. The median baseline NIHSS score was lower in DAO (13 [8–18] vs 16 [12–20], P<0.001). There were no differences in terms of age, sex, IV-tPA use, co-morbidities, or time to treatment across DAO vs PAO. The rates of post-procedure reperfusion, symptomatic intracranial hemorrhage (sICH), and 90-mortality were comparable between both groups. DAO showed significantly higher rates of 90-day mRS 0–2 (68.3% vs 56.5%, P<0.001). After adjustment for potential confounders, the level of arterial occlusion was not associated with the chances of excellent outcome (DAO for 90-day mRS 0–1: OR; 1.18, 95% CI [0.90 to 1.54], P=0.225), successful reperfusion or SICH. However, DAO patients were more likely to be functionally independent (mRS 0–2: OR; 1.45, 95% CI [1,09 to 1.92], P=0.01) or dead (OR; 1.54, 95% CI [1.06 to 2.27], P=0.02) at 90 days.ConclusionEndovascular therapy in DAO appears to result in a comparable safety and technical success profile as in PAO. The potential benefits of DAO thrombectomy should be investigated in future randomized trials.

Clinical effectiveness of endovascular stroke treatment in the early and extended time windows

“…Moreover, as less than 50% of the Trevo registry patients met the inclusion criteria for previous RCTs, it represents a unique opportunity to explore new treatment paradigms. 31,32 In conclusion, our study provides favorable data for the generalizability of the safety and efficacy of thrombectomy in the ''real-world'' setting and adds to the growing literature supporting that patients may be safely treated outside the constraints of randomized trials and strict guidelines. Other coauthors: critical revision of manuscript.…”

“…Moreover, as less than 50% of the Trevo registry patients met the inclusion criteria for previous RCTs, it represents a unique opportunity to explore new treatment paradigms. 31,32…”

Single Site performance of AI software for stroke detection and Triage

“…Distal artery occlusions may present with high clinical severity and projected disability. These studies concluded that endovascular therapy for DAO may be safe 23,24 , hence the importance that the same standards of specificity and sensitivity of proximal LVO will apply on distal occlusions. Given the low sensitivity of radiologist in detecting distal vessel occlusions an AI software can be helpful.…”

Therapeutic Advancements in the Endovascular Management of Acute Ischemic Stroke

“…104 The evolution of EVT continues with several ongoing trials aiming to extend the indication of EVT, including in LVO stroke patients presenting with mild stroke severity NIHSS score <6 (ENDOLOW [Endovascular Therapy for Low NIHSS Ischemic Strokes] and MOSTE [Minor Stroke Therapy Evaluation]), large infarct burden (eg, ASPECTS <5; large core volumes on CTP/DWI: TENSION, LASTE, TESLA, SELECT-2, and RESCUE Limit), and distal arterial occlusions (DUSK, ESCAPE-MeVO, and DIS-TALS), as previous reports have demonstrated the safety and feasibility of thrombectomy in these patient populations. 51,[105][106][107][108]…”